s m d w - dr david rosenfeld, md proctologist · scheduling.) o surgeries (hospital, outpatient, or...

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PHYSICIAN(S)Zip Code

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Last, First, (No Nicknames)PATIENT INFORMATION

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LIST THE SUBSCRIBER OF YOUR INSURANCE! SELF SPOUSE PARENT

Home Street Address

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Subscriber DOBSubscriber's Name (If not self)

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EMERGENCY CONTACT

Primary Care Physician

HOW DID YOU HEAR OF OUR OFFICE?

Zip Code

Contact Name Relationship

Gastroenterologist

Home Phone

Zip Code

Cardiologist City

Welcome to the Neighborhood Magazine Jen's List Doctor:

Other:

Internet Jen's Jen's Jen's List

Friend Relative:

I certify the above information I have provided is true and correct to the best of my knowledge. I understand that it is my responsibility to notify you of any changes in my insurance status and/or above information.

Signature: Date:

S D WM

(MM/DD/YYYY)

Cell Phone

NAME:

T.O.P - THOUSAND OAKS PROCTOLOGY DAVID B. ROSENFELD, M.D., F.A.C.S., F.A.S.C.R.S.

SPECIALIZING IN PROCTOLOGY AND COLONOSCOPY 341 SOUTH MOORPARK ROAD ♦ THOUSAND OAKS ♦ CA 91361

Phone: 805 230-BUTZ (2889)

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Save to the desktop and email to: [email protected] as an attachment.Please note the email address is not secure. If you are not comfortable emailing to a non-secure server fax the forms.

LIST ALL SURGERIES PERFORMED AND SPECIFY WHEN AND WHY.

TYPE OF SURGERY

1.

2.

3.

4.

5.

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7.

LIST ALL COLONOSCOPIES PERFORMED AND SPECIFY WHEN AND WHY.

COLONOSCOPY (Please list Doctor who Performed)

1. Y N (Doctor)

2. Y N (Doctor)

3. Y N (Doctor)

1.

2.

3.

4.

SOCIAL HISTORY: PLEASE INDICATE SMOKING, DRINKING AND HOW MUCH.

Indicate What kind? How much?

Y N

WHY PERFORMED

NAME:

SMOKING:

FAMILY HISTORY: PLEASE LIST ANY FAMILY HISTORY OF CANCER. ALSO INCLUDE FAMILY HISTORY OF COLON POLYPS, GENETIC PREDISPOSITION FOR CANCER (GENETIC TESTING CONFIRMED) CROHN'S DISEASE OR ULCERATIVE COLITIS.

Alcohol Hard Liquor

WHY PERFORMED

AGE DIAGNOSED

Years Old

Years Old

RELATIONSHIP INCLUDE MATERNAL OR PATERNAL

Please answer all questions completely

Years Old

Years Old

TYPE OF CANCER

COMPREHENSIVE HEALTH HISTORY

I certify the above information I have provided is true and correct to the best of my knowledge. I understand that it is my responsibility to notify the office of any changes in the above information.

Signature: Date: (MM/DD/YYYY)

Beer Wine

(Glasses / day-week-month)

/

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YEAR (YYYY)

YEAR (YYYY)

DATE (MM/DD/YYYY)

1. Rxn

3.

Med Rxn2.

Rxn 4. Rxn

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City: Zip:

1. 2.

Y N Y N Y NMemory loss or confusion

Nervousness or Anxiety

Painful bowel movements or constipation

Hematologic & Lymphatic

OtherOtherOther

inches lbsWEIGHT

NAME

Bruising tendency

HEIGHT

MEDICINE ALLERGIES: LIST MEDICINE AND REACTION - ANAPHYLAXIS, RASH, NAUSEA, ETC. OR 'NONE'

MEDICATIONS YOU ARE CURRENTLY TAKING: (NAME, DOSE, DIRECTIONS & REASON) PLEASE INCLUDE PRESCRIPTION & NON-PRESCRIPTION MEDICATIONS INCLUDING ASPIRIN, IBUPROFEN, ADVIL, ECOTRIN AND NSAIDS. INCLUDE ANY HOLISTIC MEDICATIONS, SPECIAL VITAMINS AND/OR SUPPLEMENTS.

Med

YOUR PREFERRED PHARMACY INFORMATION - The NAME and ZIP code are most important!

Blood clots

OTHERCoughing up blood

Wheezing Light-headed or dizzy

Chronic or frequent coughing

Head injury

Asthma

Good general health lately

Neurological

Cardiovascular

High Cholesterol (medicated)

Chest pain, discomfort or tightness

High Blood Pressure

Heart palpitations

Kidney stones

Incontinence or dribbling

Shortness of breath with walking or lying

Swelling of feet, ankles or hands

Respiratory

Gastrointestinal

Rectal bleeding or blood in stool

Name:

MEDICAL HISTORY: PLEASE INDICATE IF YOU HAVE, OR HAD, ANY OF THE FOLLOWING BY CHECKING YES or NO

Fatigue or general weakness

Change in bowel movements

Psychiatric Health

InsomniaFrequent diarrhea

Nausea or vomiting

IF YOU PRE-MEDICATE WITH ANTIBIOTICS BEFORE PROCEDURES (i.e. THE DENTIST) PLEASE INDICATE THE ANTIBIOTIC YOU USE AND THE DOSE. PLEASE INFORM THE NURSE AS TO WHETHER OR NOT YOU TOOK YOUR PRE-MEDICATION BEFORE YOUR VISIT.

Constitutional

Recent weight loss

Depression

Night Sweats

Fever

Slow to heal after cuts

Anemia

Diabetes

Loss of appetite

Convulsions or seizures

GenitourinaryAbdominal pain

Frequent or recurring headaches

Frequent urination

Burning or painful urination

Blood in urine

Change in strain when urinating

EndocrineThyroid disease

Bleeding tendency

3. Med

4. Med

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Phone #:

FAX BACK TO: (866) 518-0359

NAME:

COMPREHENSIVE HEALTH HISTORY (Cont) Please answer all questions completeley:

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PAYMENT AGREEMENT PRIVATE INSURANCE

Dr. Rosenfeld is not a preferred provider for any private insurance companies.

All patients are responsible to pay his/her bill in full at the time of service (for office visits and office procedures)

For outpatient and inpatient procedures, and surgeries, patients will need to pay the fullamount 2 weeks before the scheduled procedure. The procedure will be cancelled if payment is not made in full 2 weeks prior to yourprocedure/surgery date.

o

There is a holding fee and cancelation fee so please read the “POLICIES AND FEES” page carefully.

To help with the billing process, we courtesy bill your insurance company. The doctor has many years of knowlege, expertise and specialty training. The diagnosis codes and procedure codes are based on your signs, symptoms and findings during the exam as identified by the doctor. There are many insurance companies each with a multitude of plans. Therefore, we can not predict what your insurance company will do with the claim. Denial or underpayment of the visit and/or procedure due to your insurance company's underwriting guidelines, rules and regulations should be directed to your insurance company.

I, further, understand that the charges billed to my insurance company by Dr. Rosenfeld are for his services only and do not include any other fees such as but not limited to:

Hospital charges Pathology / Lab fees Anesthesia fees

Equipment charges Out Patient Surgery Center

charges

Payment types: Credit Card or Debit Card Health Savings Account card plus a valid Credit Card Cash NO CHECKS ARE ACCEPTED.

Payment information from credit cards or HSA cards will be held in the patient’s on line, password secure account, until the final bill is paid in full. Once paid the credit card and/or HSA card information will be deleted from the file.

I understand and agree to the above designated policy. By signing this document I authorize the office to charge my credit card, HSA card, or debit card in accordance to this policy and the fees included in the “POLICIES AND FEES” document.


Name:

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Due to the amount of work involved in scheduling colonoscopies and surgeries (surgery center or hospital scheduling, booking an anesthesiologist, faxing the appropriate forms and information, etc.) it is very difficult to change the dates for patients who cancel the procedure or call to reschedule. For these reasons a cancellation-rescheduling policy along with holding fees and no show fees exist. Please read the below policies and fees.

HOLDING FEE – CANCELLATION FEE • HOLDING FEES for surgeries and colonoscopies. For all surgeries and colonoscopies

there is a non-refundable holding fee. This fee holds the date of the procedure and isapplied to the cost of the surgery or colonoscopy. If a patient does not show for theprocedure or cancels the procedure and does not reschedule, the holding fee is non-refundable. For example, if a patient pays $750 for a colonoscopy and does not show orcancels and does not reschedule, they will be refunded $550.00. The fees are shownbelow:

o Surgery $250.00 o Colonoscopy $200.00

RESCHEDULE POLICY AND FEES • A reschedule or no show fee prior to the visit or surgery incur the below fees:

o Office visits - $50.00 (Payment of this fee must be received on the day of therescheduled office visit.)

o Colonoscopies - $100.00 (Payment of this fee must be received before re-scheduling.)

o Surgeries (hospital, outpatient, or office) - $300.00 (Payment of this fee must bereceived before re-scheduling.)

• PATIENTS MUST CALL THE OFFICE TO RESCHEDULE A PROCEDURE. CALLINGTHE SURGERY CENTER OR HOSPITAL TO RESCHEDULE DOES NOT COUNT. If wedo not hear from the patient in the appropriate time the reschedule fees above will becharged to the card.

I understand and accept the above policies and fees. By signing the below I authorize, if applicable, the fees above to be charged to my credit card.

Signature: Date:

Definitions: • Cancellation – Calling to cancel a surgery, procedure or office visit without

rescheduling.• Reschedule – Calling to change the date of a surgery, procedure or office visit.• No Show – Not showing up for a surgery, procedure or office visit.

(MM/DD/YYYY)

POLICIES AND FEES HOLDING - CANCELLATION

RESCHEDULING

Name:

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Dr. Rosenfeld, and his staff, observe and respect a patient’s rights and responsibilities without regard to age, race, color, sex, national origin, religion, culture, physical or mental disability, personal values or belief systems.

Patients have the right to: Considerate, respectful and dignified care and respect for personal values, beliefs and

preferences. Respect of personal privacy. Receive information about health status, diagnosis, the expected prognosis and expected

outcomes of care, in terms that can be understood, before a treatment or a procedure isperformed.

Receive information about unanticipated outcomes of care. Obtain information concerning fees for services rendered and the office’s payment policies. Receive information from the physician about a proposed treatment of procedure as needed in

order to give or withhold informed consent. Participate in decisions about the care, treatment or services planned and to refuse care,

treatment or services, in accordance with the law and regulation. Have family be involved in care, treatment, or services decisions to the extent permitted by you

or your surrogate decision maker, in accordance with the laws and regulations.

Patients have the responsibility to: Be considerate of other patients and of the office personnel. Report if the planned course of treatment including pre-surgery, surgery and post-surgical care

is not clearly understood. Ask questions when any care, treatment, or services are not understood. Keep appointments, and when unable to do so for any reason, notify the office following the

Policy and Fees page. Promptly fulfill your financial obligations to the office including charges not covered by

insurance. Pay for copies of your medical records (up to a $25.00) Page Dr. Rosenfeld to your Cell Phone if your home phone doesn’t allow “restricted caller” to

ring through on your line. Pay the fee for the Doctor to fill out forms for your employer, disability, etc. in the amount of

$15.00 to $25.00 (the fee varies depending on the complexity of the forms.)

I understand and accept my Patient Rights and Responsibilities’.


Name:

PATIENT RIGHTS AND RESPONSIBILITIE’S 6 of 7

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To the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations of the Health Insurance Portability and Accountability Act (HIPAA)

I understand that as part of my health care, David Rosenfeld M.D. originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment,• A means of communication with the health professionals who contribute to my care,• A source of information for applying my diagnosis and surgical information to my bill,• A means by which a third-party payor can verify that services billed were actually

provided,• A tool for routine healthcare operations such as assessing quality and reviewing the

competence of healthcare professionals.

I have the following rights and privileges:

• The right to review the notice prior to signing this consent,• The right to request restrictions as to how my health information may be used or

disclosed to carry out treatment, payment, or health care operations.

I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

Please list, if any, person(s) whom we may inform about your medical condition, diagnosis, and/or financial account:

Name: Phone Name: Phone

Can appointment reminders and confidential messages be left on your answering machine or voicemail? YES NO

Phone number to call and leave a message

I understand the above information. :

Date: (MM/DD/YYYY)

Name: Signature:

HIPAA FORM 7 of 7

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s m d w - dr david rosenfeld, md proctologist · scheduling.) o surgeries (hospital, outpatient, or...

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